2020 American College of Rheumatology Guideline for the Management of Gout

John D FitzGerald, Nicola Dalbeth, Ted Mikuls, Romina Brignardello-Petersen, Gordon Guyatt, A M Abeles, Allan C Gelber, Leslie R Harrold, Dinesh Khanna, Charles King, Gerald Levy, Caryn Libbey, David Mount, Michael H Pillinger, Ann Rosenthal, Jasvinder A Singh, James Edward Sims, Benjamin J Smith, Neil S Wenger, Sangmee Sharon Bae, Abhijeet Danve, Puja P Khanna, Seoyoung C Kim, Aleksander Lenert, Samuel Poon, Anila Qasim, Shiv T Sehra, Tarun Sudhir Kumar Sharma, Michael Toprover, Marat Turgunbaev, Linan Zeng, Mary Ann Zhang, Amy S Turner, Tuhina Neogi
Arthritis & Rheumatology 2020 May 10

OBJECTIVE: To provide guidance for the management of gout, including indications for and optimal use of urate-lowering therapy (ULT), treatment of gout flares, and lifestyle and other medication recommendations.

METHODS: Fifty-seven population, intervention, comparator, and outcomes questions were developed, followed by a systematic literature review, including network meta-analyses with ratings of the available evidence according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology, and patient input. A group consensus process was used to compose the final recommendations and grade their strength as strong or conditional.

RESULTS: Forty-two recommendations (including 16 strong recommendations) were generated. Strong recommendations included initiation of ULT for all patients with tophaceous gout, radiographic damage due to gout, or frequent gout flares; allopurinol as the preferred first-line ULT, including for those with moderate-to-severe chronic kidney disease (CKD; stage >3); using a low starting dose of allopurinol (≤100 mg/day, and lower in CKD) or febuxostat (<40 mg/day); and a treat-to-target management strategy with ULT dose titration guided by serial serum urate (SU) measurements, with an SU target of <6 mg/dl. When initiating ULT, concomitant antiinflammatory prophylaxis therapy for a duration of at least 3-6 months was strongly recommended. For management of gout flares, colchicine, nonsteroidal antiinflammatory drugs, or glucocorticoids (oral, intraarticular, or intramuscular) were strongly recommended.

CONCLUSION: Using GRADE methodology and informed by a consensus process based on evidence from the current literature and patient preferences, this guideline provides direction for clinicians and patients making decisions on the management of gout.

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